07153 (MFD5)Address 78-313 Scarlet Court
Boulevard Deve
T,i-t4t 4 4 Q"
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Mailing
Address 777 S. Main Street Suite 105
CityZip Tel.
Orange CA 192686 1 714-54.7-3056
Contractor
. Sam
Address
State Lic. I City
& Classif.461814 Lic. #
Arch., Engr.,
Designer
Address Tel.
utyI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am llcenskl under provisions of Chapter 9 (commencing with Section
7000) of Division 3/ offtlte'Businessran_d Professions Code, and Pmy license is in full force and
effect.'", "_�./ v�- ate �" ... .F. . � d
SIGNATURE / t . `•-. - " .._ DATE
OWNER -BUILDER DECLARATION
1 hereby affirdn that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Busf7ess and Professions Code: Any city or county which requires a
Permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions. Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,-
provided
mployees;provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.) ,
❑ I, as owner of the property, am exclusively contracting with licensed contractors to torr
strucl the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATIOWDECLARATION' f/
I hereby affirm that I have a certificate of consent'to self -insure, or a certificate of
Worker's Compensation Insurance, or,a,certified, copy thereof.,(Sec. 3800, Labor Code.)f ,
Policy No. Company<%., •. i./ d ! ¢tom.. / . _
❑ Copy.is filed with the city.❑ Certifred'co � µ,t
py is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(this section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
=any person in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date owner
NOTICE TO APPLICANT: ff, alter making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shalt be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lenders Name
Lender's Address
This is a building permit when property filled out signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certity that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of
City, State,
No.
BUILDING: TYPE CONST. OCC: GRP:.•
A.P. Number 613-790-013
07153
Legal Description SLO #27 Wit x`257
Project Description PUR 2
Sq. Ft. 912 No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.-
316.23
Const.
486.5U
Mech.
54. Li'l
Electrical
67.14
Plumbing
11241D
S.M.I.
4.62
Grading
Driveway Enc.
Infrastructure
1,467. ST—
TOTAL
REMARKS-1r.k.- 11 1—,
T .r Arq
°.'tS✓s�t.7f.S"'it'.t'(96 ''..:)litS,JO1
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date 2/21/90Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
A.C. UNIT
2ND FL SQ. FT.
SLAB GRADEe4OUGH
YARD SPKLR SYSTEM
PLUMB.
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
STORAGE TANK
FORMS
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
DUCT WORK
DRAINAGE PIPING
CAR P. SQ. FT.
S (ROUGH)
METER LOOP
WALL SQ. FT.
HEATING (FINAL)
DRINKING FOUNTAIN,
SQ FT ®
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
GROUT
FLOOR DRAIN
MECHANICAL FEES
SERVICE
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTOHDISH)
APPLIANCE DRYER
WATER SYSTEM
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
GRADING
cu. yd.
g plus x$
LAUNDRYTRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1% c
SEWAGE DISPOSAL
FIREPLACE
SQ.FT.GAR ® 3Vic
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
TNST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADEe4OUGH
PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
/
FOUND. REINF./r y
III G/
S (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
g plus x$
=E
LUMBER GR.
FINAL INSP., �d
FRAMING `7 pyo T
l
FINAL INSP.
ROOFING
P
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LACING
MESH
INSULATION/SOUND Q L
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
'
GARDEN WALL FINAL
1